Girls/Boyz First!! Peer Mentor Application

Name_______________________________ Date___________________________

Home Address_______________________________________________________

E-mail_____________________________________________________________

Year in School_______________________________________________________

TA Advisor_________________________________________________________

What is the best way to reach you? ______________________________________

Which days are you available to mentor after school?________________________

Why do you want to be a mentor?

What experience or interests do you have that may be relevant to mentoring?

What experience do you have working with youth?

What are your strengths?

What are your weaknesses?

Please rank your comfort level for each of the following:

1 = (no way!) 5 = (total comfort)

1 2 3 4 5 Working with a quiet, reserved child.

1 2 3 4 5 Working with a child who is outgoing and active.

1 2 3 4 5 Working with "at-risk" youth.

1 2 3 4 5 Discussing issues of substance use and abuse.

Please indicate any subjects you would find difficult in a mentor/mentee relationship.

REFERENCES:

Please list 3 references. Two teachers, one community member

Name___________________Relationship_______________

Phone_____________

Address____________________________________________

Name___________________Relationship_______________

Phone_____________

Address____________________________________________

Name__________________ Relationship_______________

Phone_________

Address_________________________________________

______________________________________________

Have you ever been convicted of a crime? ______ If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature_____________________________________Date_________

Please return to:

Ivy Zeller, CVND 18 Langdon Street, Montpelier, VT 05602.

Thank you! You can also reach me at 223-4949, or izeller@verizon.net